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038-1087-20-100
Wisct sin `OcVartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety,:nd Building Division INSPECTION REPORT Sanitary Permit No: 515148 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. Permit Holder's Name: City Village X Township Parcel Tax No: Brotzler, David I Star Prairie, Town of 038 - 1087 -20 -100 CST BM Elev: In BM sp. BM El v: Descriptio ' Section/Town /Range /Map No: l U D �V C !7 21.31.18.358c TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark A6 lob 6 n1 �Q + �� ✓ \ WW G l �L�'7YG 'Z �1 Alt. BM —a ma /1t n Aeratio Bldg. S er Holding St/ i ItAn�et L 76 el St/ t/H utle TANK SETBACK INFORMATION V it 0 q7• S/ TANK TO P/L WELL BLDG. Vent to it Intake ROAD Dt Inlet Septic Dt Bottom Is � eader/ an. 9 �. Aeration D ist. P ipe f Holding Bot. System Final G e a PUMP /SIP N INFORMATION�� �0 �9 �S Manufacturer Demand St Cove GPM Wvu /D 0• Model Number TDH Lift Friction Loss stem Head TDH Ft Forcemain Length ia. Dist. t ell SOIL ABSORPTI SYSTEM 2Z I,ti rt Uff BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / f1 /_ �Y SETBACK SYSTEM TO V ( P/ /L BLDG WE LAKE /STREAM LEACHINq Manuf r r: ?,r INFORMATION CHAMBER R C ✓}� Type System: u �w / Model Number: D T IBUTION SYSTEM / Header/ anifold Distribution // x Hole Size x Hole Spacing ant t Air IntakFNo PI Pe(s) �/ 0 (oS („ f �� ength Dia Length Dia Spacing t � SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center I1 Bed/Trench Edges Topsoil / 0 Yes E] No [] Yes COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / 2 / Inspection #2: / / Location: 1067 210th Avenue Somerset, WI 54025 (NW 1/4 NE 1/4 21 T31 N R18W) NA Lot 1 Parcel No: 21.31.18.358c 1.) Alt BM Description = I or a I'�"� ►�;�ri �t� -� CAL' �'��� 2.) Bldg sewer length = •P.�►S -h "L 2 -amount of cover= Plan revision Required? 0 Yes X Use other side for additional information. _ G " / - -- 'le G� -- Date Insepctor's Signa ure Cert. No. SBD -6710 (R.3/97) i ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence (Street address) /T located at: 90j '/4, Ne '/4, Section Z/ , Town 3 I N, Range _1_ W, Town of �S ,t' 1�/ IeiC , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 7��/�lf 9�Z 501 . Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: / a- Construction: Prefab Concrete Steel Other Manufacturer (if known): (it/6'8)L_ Age of Tank (if known): - 7 Permit number (if known) % 2 3 (Licensed umber Signature) (Print Name) (Title) (License Number) MP /MPRS Zoo (Date Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 f S EAID cornmerCe.W1.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St Croix sco n s; n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) Oepartmatit at Commerce 5 / 5 I q Sanitary Permit Application State Transaction umber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental V A - unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary p urposes in accordance with the Privacy Law, s. 15.04 1 m , Slats. � /�47 2,) / L�•• / � I. Application Informati — lease Print All Information / (� Property Owner's Name Parcel # Dave Brotzler 038- 1087 -20 -100 Property Owner's Mailing Address Property Location �/ G 1067 210th Ave o CRO11 couNl Y Govt. Lot f Q FICE City, State Zip Code e um er NW ' /4, NE /4, Section 21 Somerset, WI. 54025 715- 246 -2405 3\ (Check One) II. Type of Building (check all that apply) ,(,� Lot # T N; R 18 ❑E QW ❑ 1 or 2 Family Dwelling — Number of Bedrooms l k0eq X J__ Subdivision Name 14,C Block # ❑ Public /Commercial — Describe Use Aff ❑ City of ❑ State Owned — Describe Use p CSM Number Z5 ❑ Village of ' 74 711808 2.24 Acers ❑✓ Town of Star Prairie III. Type of Permit: (Check onfy one box on line A. Complete line B if applicable) A. ❑ New System ❑✓ Replacement ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) System It '17-) Y-Y - 19 B. ❑ Permit ❑ Permit Revision ❑ Change of Permit Transfer to Li Previous Permit N er and Date Issued Renewal Before Plumber New Owner a Expiration IV. Type of POWTS Sy stem/Component/Device: Check all that appl ❑✓ N on- Pressuri In- Ground ❑ Pressurized In- Ground El At -Grade ❑ Mound? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil S ❑ Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Inf rmation: Design Flow d) Design Soil pplication Rate(gpdsf) Dispersal Area lred s Disp �a T✓� ed (sl) System Elevation 600 .7 858 or 34.32 (AW chambers) 35 S Chambers 95.4 a � . VI. Tank Info Capacity in Total # of Manufacturer Material Gallons Gallons Units New Tanks Existing Tanks w z4e AJZ0 Septic or Holding Tank 1000 eXlSting 2 Wickes / unknown Prefab Concrete Dosing Chamber VII. Responsibility Statement- I, th e undersigned, assume responsibility for !pW . 1&UaajA4Jke POWTS shown on the attached plans. Plumber's Name (Print) Plumber's afar MP/MPRS Number Business Phone Number Mike Rogers 1 225094 715.235 -1132 Plumber's Address (Street, City, State, Zip Code) E4457 Hwy 12 Menomonie WI. 54751 VIII. County /De artment Use Onl Approved _ Permit Fee Date I sued Issuing nt Signature Owner easo enial $ a 23 �q IX. Condit jMpt W"Lq*easons for Disapproval ° 1. Septic tank, effluent lifter and dispersal cell must all be services / mairdained as per management plan provided bypltlmtisl'. i /,r,y � /2 e ' /7 t- 2. All setback t8qu reWw is mtast;be ma intainad 1` nab , Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 David J. Steel David & Ruth BroWer 1699150tH St. CST POWTSM NW l /4,1E1 /4,S21,T31N.RJ 8 ! New Ricbmond, Wl 54017 Lie. #248956 ToFvnn of Star Prairie, St Croix Co. Direct 715 -760 -0347 Csm Lot 2 Fax 715246 -0318 � �- 113 � i l f ` Legend N -- = Benchmwk Ble. 1 7ft Top of 3/4" PVC pipe = Alt Benchmark EI 10 Top of 3i4" PVC pipe �{ ���� = Borings Add Elevations B1= 99AO ft �Z 4 B2= 98.40 ft 98,40 it o B4 t 0.00 f1 f i � is (91 VA Tm _� J1iD yY►f l ECOPY David I Steel David & Rx6 BroWer 1699 150th CST-POWTSM th s tt' St NW Now Riebwond, WI 54017 5 347 Uic. #248956 Town of Star Prairie, St Croix CO- Direct '715- 76 -0 5 � CSM Lot 2 115-24"318 Legmd N A = Benchmark Me. 100-00 ft Top of 3/4" PVC pipe pipe 100,00 7tI • = Alt Benchmark El 100.20 ft Top of N4 PVC Pipe Add tAle, Elevations Boring Elevations 11 , V B1 99AO ft B2 = 98.40 ft 3 .4 98.40 ft o `a B4 0.00 ft V J vo� 47 j— y4e CL- D*A - 69d PA ) IL EVALUATION REPORT #2121 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings Steel's Soil Service Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. r OA- 1087-20-100 Please print all information. Reviewed By Date Personal information you provide may be use (Privacy Law, s. 15.04 (1) (m)). fV GLJ y( Property Owner Property Location David & Ruth Brotzler Govt. Lot na NW1 /4, NE1/4, S21, T31N, R18W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1067 210th Ave. ;v1X 6UUNTY 1 na CSM 7/1808 2.24Acres City State AAMOt W & MMWrOeTr City 1 Village I Town Nearest Road Somerset WI 54025 j 715 - 246 -2405 Star Prairie 1 210Th Ave New Construction Use: I ] Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement P i I Public or commercial - Describe na Parent material Outwash Flood plain elevation, if applicable na ft. General comments Conventional system, system elevation to be determined at the time of instalation. Trenches spaced and depth to code. and recommendations: Boring i, Boring # L_ pit Ground surface elev. 99.40 ft. Depth to limiting factor 120 in. P g Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistency Boundary Roots GPD 1ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I •Eff#1 *Eff#2 1 0 -2 10yr3 /1 none I 2msbk mfr CS 2c 0.6 0.8 2 2 -16 10yr4 /4 none sl 2msbk dfr CS is 0.6 1.0 3 16 -42 7.5yr4/4 none grcos osg mvfr CS na .7 1.6 4 42 -120 7.5yr4/6 none cos osg ml na na 7 1.6 / l 2 Boring # Boring Pit Ground surface elev. 98.40 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -2 10yr3 /1 none I 2msbk mfr cs 2c 0.6 0.8 2 2 -36 10yr4 /4 none SI 2msbk dfr cs lc 0.6 1.0 3 36 -48 7.5yr4J4 none grcos osg mvfr cs na .7 1.6 4 48 -120 7.5yr4J6 none cos '` osg ml na na 7 1.6 77 " Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < mg /L and TSS < 30 mg /L CST Name (Please Print) Signatuye CST Number David J. Steel - 1 . - " 248956 Address Steel's Soil Service Date Evaluation Conducted Telephone Number 1699 i1 50th St New Richmond, WI 54017 8/10/2009 715 - 760 -0347 SBD -8330 (R.07100) Property Owner David & Ruth Brotzler Parcel ID # 038 - 1087 -20 -100 Page 2 of 3 ' F I j Boring 3 Boring # Pit Ground surface elev. 98.40 ft. Depth to limiting factor 120 in. Soil Application Rate L Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -2 10yr3 /1 none I 2msbk mfr cs 2c 0.6 0.8 2 2 -18 10yr4 /4 none sl 2msbk dfr cs is 0.6 1.0 3 18 -42 7.5yr4/4 none grcos osg mvfr cs na .7 1.6 4 42 -120 7.5yr4/6 none cos osg ml na na 7� 1.6 F Boring Boring # 1 I Pit Ground surface elev. p 9 in ft. De th to limiting factor . ISoil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F Boring Boring # Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 50 mg /L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD- 83 3 0 (807/00) Steel's Soil Service STEEL'S SOIL SERVICE 3 of 3 David J. Steel David & Ruth Brotzler 1699 150th St. CST- POWTSM NW1 /4,NE1 /4,S21,T31N,R18W New Richmond, WI 54017 Lic. #248956 Town of Star Prairie, St Croix Co. Direct 715- 760 -0347 CSM Lot 2 Fax 715- 246 -0318 Legend N s ♦ = Benchmark Ele. 100.00 ft Top of 3/4" PVC pipe • = Alt Benchmark El 100.20 ft Top of 3/4" PVC pipe ❑ = Borings Boring Elevations BI = 99.40 ft B2 = 98.40 ft r4- Yo 1 B3 = 98.40 ft wo B4 — 0.00 ft 3 , � ' ,y � J 7A'A TAAk `+a V v `� rn f� J / � �� � rOt1 ✓fit(' G � � / /T, /� L. 428386 CERTIFIED SURVEY MAP LOCATED IN THE NWI /4 OF THE NEI /4 OF SECTION 21, T31N, RISW, TOWN OF STAR PRAIRIE, ST. CROIX COUNTY, WISCONSIN. OWNED BY: GEORGE a YVONNE BROTZLER R T. 2 NEW RICHMOND, WI 54017 * *SEE SHEW 2 OF 2 FOR DESCRIPTION *# APPROVE O e SET 1"x24" IRON PIPE WEIGHING MAY Q : 'x;87 1.13 LDS. PER LINEAL FOOT. ST. CKOIX 0-;:- )•''': COMPREHENSIVE PAK;(S YLA:r i•t`l(i AND ZONING COMMITTif) NI /4 CORNER OF SECTION 21, HE CORNER OF SECTION 21, T3f N, RISW. (COUNTY T31N, R16W. (COUNTY MON UME.NT FOUND). MONUMENT FOUND). NORTHLINE OF THE NEI 14 2 107 R. � $ 390.0 � S T REET „ S89 38' E - - N89 W 935.22' �n .a 1325.22' T _ ro S89p58'18_'E 390.01` — N n rlant- of- way line I ` 10 O 0• O N N O Oct cm cm - --� W LO T I 3 J• o 'n 2.24 ACRES m O N (97.e00 s 0. FEET) W N 2.01 AC. TO R.Q.W. N w 2 (67.666 SO. FEET) p a • a• J J• Z • 4.4' N89-.34'38"W 390.00' 6 Z • existing fence UNPLATTEO LANDS �EA6TLINE OF THE NWI /4 NOTE BEARINGS ARE REFERENCED OF THE ME TO THE NORTHL)NE OF THE HE 1/4 OF SECTION 21 (ASSUMED SEARING). Oae ,� {` G o W E $ JAMES M. S • WEBER % B S F, L E D � SPRING VALLEY MAY 7, l9b-1 .y wls. a l� ..w..• • w ae� SCALE I" = loo' t; ,I••:w' a16iB O.IrMI►I ;'aaii • O' 50' 100 200' 8 �1 JAMES M. WEBER 5 -1804 WEGERER, WEBER AND ASSOC. DATED VOLUME 7 PAGE 1808 S MEET ' I OF 2 87.60 THIS INSTRUMENT DRAFTED BY Chamber SAS SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Soil Absorption Systems Brotzler Owner's Name 9/22/2009 Review Date �Y or N Highly Pretreated Effluent 3 ft Suitable Soil Below System 16 in Chamber /Unit Height2 ke( 3 v✓ 8 ft Maximum Bury Depth s 600 gpd Estimated Daily Peak Flow 0.70 gpd/ft In -situ Wastewater Infiltration Rate 857.14 ft Chamber /Unit Area X00 EISA ft / Unit ,X # of Chambers /Units 95.40 ft Proposed SAS Elevation 1&,W Bottom Area ft / Unit Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 97.73 104.73 1 99.40 120 92.40 98.07 Yes 2 98.40 120 91.40 97.07 Yes 3 98.40 120 91.40 97.07 Yes 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is equivalent to top of aggregate. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. Version 4.0 (04/03) POWTS OWNER'S MANUAL MANAGEMENT PLAN ]FILE INFO TION SYSTEM SPECIFICATIONS C)wner 0 Septic Tank Capacity 7-S47 gal C NA Permit Septic Tank Manufacturer �,✓ p NA DESIGN PARAMETERS EffluentFilter Manufacturer C NA Number Number of Bedrooms'100gpd/bedroom p NA Effluent Filter Model C NA of Commercial :Units NA Pump Tank Capacity gal NA Estimated flow (average)* gaUday Pump Tank Manufacturer NA Design flow (peak), estimated x 1.5* gal/day Pump. Manu acturer A Pump Model Soil Application Rate gal/day P t�lA Tnfluent/Eff luentQuality (NAM) Monthly Average ** Pretreatment Unit O NA C Fats, Oil &- Grease (FOG) Sand/Gravel Filter O Peat Filter Biochemical Oxygen Demand (BODs) 30 mg/L ❑Mechanical Aeration ❑Wetland m Total Suspended Solids (TSS) 5 220 gtL ' E3 Disinfection C Other: 5 250 mg/L Manufacturer: Model: Pretreated Effluent Quality p Monthly Average * ** Dispersal Cell(s) Biochemical Oxygen Demand (BODs) Xm -ground (gravity) ❑ In-ground (pressurized) S 30 mg/L C At -grade C Mound Total Suspended Solids (TSS) Fecal Coliform (geometric mean) 5 30 niglL ❑Drip -line ❑ Other: <10 {cfu/l00m1 f$Leaching Chamber Manufacturer Maximum Effluent Particle Size 1/8 inch diameter Model Approval Stipulation * Wastewater Flow Verification on and calculations: Soil Application Rate - ___ - gpd/ft Area Req. ft - (other than bedroom based) Absorption Area Credit per unit ft2 Minimum Number of Chambers. q Aggregate Design Flow/Loading Rate= min ** Values typical for domestic (non-commercial wastewater Materials: all materials must comply with WI Ad E. Code and septic tank effluent. COMM84 and be installed per manufacturers specifications ** *Values typical for pretreated wastewater. and approval letters. DESIGN CRITERIA C "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse etal.1990) C "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler. Publication 15.22 C . "Desiga of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6 C "Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis -ASAE Publications 5 -77 and "Design Manual Onsite Wastewater Treatment and Disposal Systems ". EPA 625/1 -80 -012 October 1980 C SBD 10570 -P (8.6/99) "At -Grade Component Manual Using Pressure Distribution C SBD - 10567 P 6/99 "In Ground Absorption tron Com rp ponent Manual ci SBD - 10705 -P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0 ❑ SBD - 10628 -P (N.6199) "Recirculating Sand Filter System Component Manuar C SBD - 10656 -P (N.6199) "Split Bed Recirculating Sand Filter System Component Manual" o SBD = t0572 P (8..6199) "Mound 'Cbmponent'Manual" C SBD 10691 -P (N.01/01) "Mound Component Manual" Version 2.0 C SBD - 10595 -P (86%39) "Single Pass Sand Filter Component Manual" C SBD - 10657 -P (8.6/99) "Drip -line Effluent Disposal Component Manual" C SBD - 10573 -P (R 6/99) "Pressure Distribution Component Manual" C SBD - 10706 -P (N.01 /01) "Pressure Distribution Component Manual" Version 2.0 C Drip -line Effluent Dispersal Component Manual for Multi -flo Onsite Wastewater Treatment Units MAINTENANCE AND MANAGEMENT MAINTENANCE MOMORING SCHEDULE Service By Service Frequency Inspect condition of tanks At least once every p months =Ycar(s) (Maximum 3 yrs.) Pump out contents of tank(s) When comb ed sludge and scum equals one -third (I - of tank volume Inspect dispersal cells) At least once every ❑ months 1K year(s) (Maximum 3 yrs.) Clean effluent filter At least, once every D months ear(s) Inspect pump, controls &alarm At least once every M months ears) ❑ NA Flush laterals and pressure test At least once every ❑ months p year s M NA Valves At le once every e] months C year(s) NA Oth er: At least once every C months T3 year(s) jjr NA Page of START UP For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process, and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a seppage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. OPERATION The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS'. The installation of water - saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water soMners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note. this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non - biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up, [3 Valves Valves shall be operated in the following manner: [3 AIarms Alarms should be tested on aregular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a l day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back -up of sewage into the dwelling or surfacing. INPECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications:: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). bZ-0stptic Tanks Component Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any backup or ponding ofeffiuent to the ground surface. Access openings used for service or assessment shall be sealed' and/or locked upon completion of service. Any defects shalt be promptly corrected. Exposed openings; greater than & inches in diameter shall be secured with an effective locking device to prevent accidental or unauthorized entry into the tank When the combination of sludge and scum in any tank exceeds one -third (1/3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. r3 Pump Chamber/Treatment Tanks Component The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be made for leaks, backups, surfacing,, missing or broken security devices and other hardware and the condition of the filter. Any service needs or repairs shall be promptly taken care of �61- Ground Gravity Component Dispersal Cells The inspection shall include recording the. levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding at depths greater than 75 % of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. Page of_ Cl Mound, At- Grade, In- Ground`Pressure The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. The pressure distribution system is provided with an opening at the end of each lateral; to be used for flushing. The laterals should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to ensure that equal distribution of effluent is occurring to promote the longevity of the system. REPORTS Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin. Administrative Code. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code. - All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. - The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or other inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot repaired the following measures have been, or must be taken, to provide a code compliant repl cement system: suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for new soil from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site eyaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site.has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. «WARNING» ' SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT: RESCUE OF 'A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT` OR 1E13POSSIBLE. ADDITIONAL COAD4ENTS POWTS ,INSTALLER' ' POWTS MAINTAINER , Name o 0-1 Flu .1 Name Phone 7 / ---) 3 S -// Z Phone SEPTAGE SERVICING OPERATOR (Pum.per)' LOCAL REGULATORY AUTHO Name Agency 6 Phone Phone d K: \WPDATAIEWOWTS OWNER'S MANUAL.doe Page of Private On -Site Wastewater Treatment System ( POWTS) Index & Title Sheet Owner gr Project Name and System Type: Location: Street Address Ili Legal Description Township /County Contents: Page 1: Sanitary Permit Application Page 2: Plot Plan Page 3: Soil Test A Page 4 . �.. ��u•1 G�� Page 5: Septic Tank Maintenance Agreement Page 6: Warranty Deed Page 7: POWTS Owner's Manual Management Plan Page 8: POWTS Owner's Manual Management Plan Page 9: POWTS Owner's Manual Management Plan Page 10 Certified Survey Map Page 1 : : Ge Attachments: Plumber /Designer: Mike Rogers Signe ! Credential Number: 225094 Date: Z/ Zug ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM i Owner/Buyer Mailing Address Property Address (Verification required from Planning Department for new construction) City /State 4 \Tq - 1_ Parcel Identification Number NJ I.F.f Al. DF- 1 9CRIMON Property LocatioAN ' /a,NS- ' /4, Sec. T�N -R_12LW, Town of Subdivision dl `� �� S�- CcOlxC�i Lot # Certified Survey Map # S 6 ., Volume Page # ` at Warranty Deed # U _� —�1 P6 �— , Volume Page # Spec house ❑ yes -W no CVRTF,M MAUVTF.NANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The ro owner agrees to submit to St. Croix Zoning Department a certification form signed b the owner and b C , P PertY ag g P gn Y Y a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE nWNF.R CF.RTMCATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the ro perty described above, b virtue of a warranty deed recorded in Register of Deeds Office. Q\ ^ a SIGNATURE OF APPLICANT� DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.****** * * Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Z47 4 P 462 JL STATE BAR OF WISCONSIN FORM 3 - 1998 }{A ra QUIT CLAIM DEED HEGILEEN H. WAL.SH ST, TER OF DEEDS Document Number `' vi RECEIVCD FOR RECORD �cxYi k�r c� This, Dee,, made .. bejyyeen „ �,��.y I2115/2033 COOPH QUIT CLAIr., DEED EXEMP r # v Grantor, and v �� O- et �pQ REC FEE:. id0 TRAMS FEE; U.v'-%li, w r ftc- C 5 d o\ 'C e ILI, COPY FEE: CC FEE: Grantee. PAGES: 1 rant quit claims to Grantee the foll owing described real estate in t '✓ C� I County, State of Wisconsin: ll Recording Area ` Name and Return Address Parcel Identification Number (PIN) 0 ( (\ F This homestead roperty. C �f� 2 Q Vt�►.G C C �t \`� C� C 1 V �i t� (is) (is not) O J i o � , Together with all appurtenant rights, title and interests. Dated this 1 day of 0'V I•© 0'>' o SEAL (SEAL) (SEAL) 6� 2\-Q-i (SEAL) J,G -tCJV� (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) State of Wisconsin, SS. CourlJ authenticated - this day of Personally came before me this ! day of bw , the above 'named baw i _+ G 6rol zkr TITLE: MEMBER STATE BAR OF WISCONSIN to Of not, me known to be the person who executed the fore authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. `k`* ►fElitN O . • ii THIS iNSTRUMENT_WAS DRAFTED BY • Notary Public, State of Wisconsin My commission is permanent. (If not, (Sig natures may be authenticated&r acknowledged. Both are not g ` ( v necessary.) ` Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. QUIT CLAIM DEED FORM No. 3 = 1998 Milwaukee, Wis. m CD 3 co m • v `�° 3 `-° 3 " O Us - - z o o m z; m z p Lr, CO I A N)° t. �. 3 O r '�, Cnn O ° N U O N co 4 F7 w CL A cn a CD N= 2i a (D m ° ao � O V.3 N N N N Q W CO N O N O n a� O a 0 � N N p H N O C fl1 -4 O "� G D a Z D \ O D (D CO a Z, D N a p ',, j ` •C D 71 N p� S 07 <_ p D C A A A c W C Pi -< O O N Z O N N co OVD O c a CD OOO m OOO a t�i> ai zg cQ v v v o� cr M G D a l N cr m 0 O' o ' N CD m v ° V N ' .d. .. CD .d. .. CA CA d (D 3 O ° a o 5 Z co o D o O o D CL > > ^' v P O 5 D P+1 • O O 0 � N CD j ro n CD C (OD N. C = N a m 3 a CD 6 CD m 6 —i fn N c N c �a — CL CL ? C CD CD CD CD < N c o 3 A z o •"•' O :'•' Z Op m N z N (D (D p CD CD o n a N C N C (D O G. O C. Q m @ I (D O N N Er d � � A NO CD 03 �on "D I N Oo n N ti CD ° O 0 O 0 O (D m trC w 0 0 0 0 " a ° o ° O a- Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER / ` f 0) �� �rp12lel TOWNSHIP Star �4! /^ � SEC. -21 T J - N -R1 W ADDRESS - r l�c JST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p � 3 a6� y et ct I� as ra INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 6eMP". WI / LJ. `�, ` r o 04 st Elevation of vertical reference point: /6'b Proposed slope at site: SEPTIC TANK: Manufacturer: �j Q�s Liquid Capacity: Number of rings used: Q Tank manhole cover elevation: � 3 Tank Inlet Elevation: p Tank Outlet Elevation: :�Iz 5 3 601//0rt *umbe46feet from nearest Road Front, Side, Rear, O j 7,::� feet From nearest property line Front,0 Side,0 Rear, n feet '� � O ! Y Number of feet from` We11 building: f (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: G .7- V Trench : Width: Length: Number of Lines: d Z Area Built: Fill depth to top of pipe: p �� Number of feet from nearest property line: d ,kront, / O Side, O Rear,® Ft. c Number of feet from well . -SLR Number of feet from building: 3 (Include distances on plot plan) . SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: J Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on j ob : License Number: 3/84:mj ,DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O! BOX 7989 BUREAU OF PLUMBING MADISON, WI 53707 NW%, NE14, S21,T31N —R18W UCONVENTIONAL 1:1 ALTERNATIVE Stet a Plan l.D.Number: III ass Town of Star Prairie O Holding Tank O In- Ground Pressure O Mound 210th Avenue NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO : DAT II David Brotzler Route 2, New Richmond, WI 54017 '1 00 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: , Byron Bird Jr. 3318 St. Croix 92537 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LAB L LOCKING COVER PROVIDED: PROVIDED: Lg YES ONO I ❑YES NO BEDDING: VENT DIA.: VENT MAT L.: HIGH WA E UMBER OF ROAD: PROPERTY WELL: BUILDING: I VENT TO RESH /� -+ ALARM' FEET FROM /� LINE: AIR INLET. ❑YES �i+10 4 C OYES �NO NEAREST � 6 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO OYES ONO DYES O NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL B TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA. SPITS LIQUID BED /TRENCH TRENCHES: I MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR PIPE DISTR. PIPE MATERIAL: NO. STR. NUMBER OF PROPERTY WELL BUILDING. V NT TO FRESH BE LOW PIPES. ABO COVER: ELEV. V. INLET E V. END. PIPE LIfyE � �J, A Co l �-7� y /off 90 7e t 7 Q c?! NEAREST° —► MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ONO SOIL COVER I TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YE ONO O YES ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED. CENTER: EDGES. ❑YES El NO El YES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.: PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED LANS DYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: 3 INEA FEET FROM LINE OYES ONO DYES ONO S T � 72 Sketch System on r( Retain in county file for audit. Reverse Side. �. -(/-` SIGNATURE: TITLE R. 01/82) Zoning Administr' DILHR SBD 6710 1 DI R SANITARY PERMIT APPLICATION COUNTY e_ In accord with ILHR 83.05 WIS. Adm. Code STATE SANITARY PERMIT# 153 � —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION FOR VARIANCE ❑ YES I NO PROPERTY NER , PROPERTY LO ATION G rr Grp' /4 '/4, S o21 T,.7/, N, R E (oriS7 PROPE0Y OWNER'S AILING ADDRESS LOT NUMBER 111LOCKNUMBER SUBDIVISION NAME df ecj , n cl CITY, STATE ZIP CODE PHONE NUMBER CITY ± r T RO AKE OR LANDMARK VILLAGE �fuV /u�Y/ 11. TYPE OF BUILDING OR USE SERVED: - A • 03 a - / 6 9 - 7 - J O-4 00 Number of Bedrooms if 1 or 2 Famil O R Public (Specify): Y ( P Y) : III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. F New b. ❑ Replacement c. El Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. W Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes r inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 4 / . Feet W Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in clallons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Gci� tk Lift Pump Tank/Siphon Chamber I I I I ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: PI b s dress (Street, City, State, ip C de): Name of esigner: a VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # CST's SS (Street, City, St e, Zip Code) Phone Number: IX. CDUNTYIDEPARTMENT USE ONLY F-1 Disapproved Sa itary Permit Fee Groundwater ate Issuin Agent Signature (No Stamps) Approved rcharge Fee ❑ Owner Given Initial ��, C Adverse Determination W X. MMENTS/ EASONS FOR DIS PROVAL: SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION ` TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater - flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained: The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Prcperty owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1 -6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.�, MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/i X 11 inches must be submitted to the county. The plans must include the following, A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. ----------------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground ater - included the creation of surcharges (fees) for a number of regulated practices which Wisco ro can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasur is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. c The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground - t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD -6398 (R.03/86) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property _ _ 0 �� r Location of Property W Section �� ..._, T N -R W Township S ( 3j , Q Mailing Address Address of Site r - Subdivision Name I Lot Number Previous Owner of Property Qy te Gam, VG v�r2 �( p'CZ� e,( Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes x No Volume _"� and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number volume and page number and the Seal of the Register of Deeds In addition, a certified survey, if available, would be I helpful so as to avoid delays of the reviewing process. If the deed description refer- ' ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATIO I (we) ce ti.6y that att statements on thi.a 6onm ane true to the best o6 my (oun) knowledge; that 1 (we) am (ah.e) the owneh (s o6 the pnopen ty des ch i.bed in this in6o4mation 6onm, by viAtue o6 a waAAanty deed neconded to the 066ice 06 the County Reg,isten o6 Deeds as Document No. ; and that I (we) n ( ) p es entey own the pnoposed site bon the sewage dispos syst (orc I (we) have obtained an easement, to hun with the above dedcAi.bed ptopeAty, bon the constnucti.on 06 said system, and the same has been duty neconded in the 065.ice o6 the County Reg.isten o6 Veedb, vA Document No. ). SIGNA OP OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE U� DATE SIGNED DATE SIGNED . DOCUMENT N o. WARRANTY DEED . THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 � l I __ - - - -- __ - - -- -- -_ .- -- ------- _— _--- - - -_._ et����Vs!'�T {S ®FEEL{ _..��arge.._Bratz.lex__ and.. Xvonne ...Brotzlez.,.._husband. -. .x -•�. y �?�,� �r� --- and -- wife. ..as ... 3oint..t-enants-- "- " "• - -- 12 .... .... ; May �I; . w�_ 4 87 _ 3:00. P :__a t;t conveys and warrants to ...Dayic _ * p $�OgIg James O'Connell . man- " .. ........... Fo" "blw of ...................................... RETURN TO I' •--•--...-••-••---•••-••-•-•••-•--•-•--.....••-•--••-------••-••-•.-"------------------------ the following described real estate in .......St•,.••CrOiX .....County, j State of Wisconsin: Tax Parcel No: .............................. i Lot One (1) of Certified Survey Map, filed May 7, 1987 in Volume "7" of Certified Survey Maps, page 1808, as Document No. 425386, being a part of the Northwest Quarter of the Northeast Quarter (NW; of NE;) of Section Twenty -one (21), Township Thirty -one (31) North, of Range j Eighteen (18) West. I; I This .. ... is not i _ ._.._....•......_. homestead property. (is) is not) I Exception to warranties: i I Datedthis ................ • .. .. ........................... day of ............. KAY ................................................. 19...$.7.. �i i! ----- •-- ---- •----- -••-- •---- • - - - - -- (SEAL) . ....... .. ........... (SEAL) G e Brotzle ........•"--•-• ................. .................•-- •- -..... - -- .(SEAL) x ,.. ". � _2 Gam/ ? t.:........... (SEAL) onne Brotzler I jl AUTHENTICATION ACKNOWLEDGMENT I I Signature (a) ............................................................ STATE OF WISCONSIN as. i� -"---"-------------"---------------...------------------- •-- •- •---- ••----- - - - - -- St. Croix u"- i authenticated this ........day of ........................... 19 ...... Personally came before me this ._�� --------- day of -"-"-----"-........---" ........................... •------ •-- •- •......----- - - - - -- May- I -•- -•......•--- -•........, 19...87. the above named ! eox- ge..axatz�.sx__.and..Yv nne- •Hratzler '--"""---•------"-----"•---------"--"------------------- •--- •- ••- •--- .....•. . . . . II - I TITLE: MEMBER STATE BAR OF WISCONSIN ----------""""-"-------------------------- •------------ ••--- •-- - - -• -• ..... - -.... (If not, .................... ............................... authorized by § 906.06, Wis. Stats.) to me known to be the person a.......... who executed the foreg n instrumen � a ow ckn edge the same. THIS INSTRUMENT WAS DRAFTED BY / Reinstra,_ Van Dyk - & Needham S.C. ..... 6 -- f New Richmond, WI 54017 *.. Ruth_. A....J_ ohnson ........ ............................ . .. ----- ••-- - -•• -• •- •••- ....- • . ..... .................... .................... Notary Public . .. S .t...Cr:alX ..............County Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 12/23/90_______ ____ _ _____ ___ 19.........) ;i i� •Names of persona signing in any capacity should be typed or printed below their signatures. KC.MillarCamprry� STAT FORM No. WISCONSIN SN Stock N O. 13002 G to ' a • S T C - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT 00 St. Croix County z d a OWNER /BUYER H rn ROUTE /BOX NUMBER C Fire Number CITY /STATE �e_ �NCN-1 � \ jNj I.IP 4 101� PROPERTY LOCATION: 1 4, 'U L 1 4, Sectio T } N, R \ _W, Town of st W Q '( 0.A6\ 4- , St. Croix County, Subdivision , Lot number 1 � J Improper use and maintenance of your septic system could result in I its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix. County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H E I /WE, the undersigned,, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 'v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. �p SIGNED DATE I II 1� St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS tI�IDUSTfiY, 11 CC DIVISION LABOR HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (H63.09(1) & Chapter 145.045) LO A ION: SECTION: HIP : S OWNS MUNICIPALITY: LOT NO.: BLK. NO.UBDIVISION NAME: u ' /WA/ a l /T3/ N /R /�'E (o sue,- ro - r �- ,� COUNTY: OWNER'S BUY R'S AME: MAILING ADDRESS: V Lra utlir Ar �Z /.��- �itd2 x� 41W0' ,, o ! 7 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL ' DESCRIPTION: IPROFILEDESCRIP PER Residence .� New ❑Replace L _ '7 RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: I MOLJND. IN- GROUND Po URE: SY s -I L HO S TANK: RECOMMEC� %SYSTEM: (optio�) e Iry If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floo indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) .0A '?cf /�, /J .24 - g� o -/;z .- �3,r is is - a s d� � � �s $S►� -KS 3 Ake- � B- a o �a'o �� 1.s o2 ° ns 7� .S ptic B- F�c7 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER Mfe6 AFTER WELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P _ 6 OWL c o? a G C P- 6 G P- se G G L P -_ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION /y u 4- -4 Z76', .�: -� s... _ ! At /...? -{ I E t n� 3 y V , ,� __ _ - --- _ ._�_ TN � ro t .,. .,_..,. a . _..� . � - ►- F i € F E � 3 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ,A! r O n ,( r l-c� �^ . — ADD ESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): o G rn x r e ZLe J < s' ad CS A:�� DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) OVER — INSTRUCTIONS FOR COMPLETING FORM 116 - SBD - 6396 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASEL} ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shmvn here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; J. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10, If the information (such as flood plain, elevation) does not apply, place; N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copiers and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 MAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10 ") BR - Bedrock cob Cobble (3 - 10 ") SS - Sandstone gr - Gravel (under 3 ") LS - Limestone "s - Sand HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate need s - Medium Sand W - Well fs -- Fine Sand Bldg - Building Is - Loamy Sand > -- Greater Than � sl Sandy Loam < Less Than "l -- Loam Bn Brown * sit - Silt Loam BI - Black si Silt Gy - Gray * cl - Clay Loam Y Yellow set - Sandy Clay Loam R - Red sicl - Silty Clay Loarn mot - Mottles see; Sandy Clay en -- With sic - Silty Clay fff - feuv, fine, faint �c Clay cc cornmon, coarse pt -- Peat IT1111 Many, nIeciiur?r rn Muck d - distinct p - pror meat HWL - High vvater level, Six general soil textures surface water for hcfuid waste disposal BM - Bench Mark VRP -.. Vertical Reference Point TO THE OWNER: This soil test report is the first stcrp in securing a sanitary hermit The county or the Department may rNlttest verification of this sail test in the field prior to rls'r nit issuarx;e. A complete set of plans for thr>, private sewate system and a permit application must he submitted to the appropriate 'oral authority in order to obtain a permit. The sanitary permit mist be obtained and hosted prior to tn;, st<rt of any construction. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND_ PERCOLATION TESTS (115 MADISON, WI 53707 HUMAN RELATIONS (H63.090) & Chapter 145.045) i LO A I SECTION: ICIP LITYLOT NO.:BLK // n 2 / /T3/ H /Ri�E c� tO�WN17H i � at� COUNTY: OWNER'S BUY R'S AME: MAILING ADDRESS: DATES OBSERVATIONS MADE USE 0 L A I N TESTS: NO.BEDRMS.: COMMER 777 ❑Replace Lyt _. �.•� RATING: S= Site suitable for system U= Site unsuitable for system r2 �SEI N- GROUND - PRESSURE: S STEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM:(optior Zs ❑u os �U as U 6�� Funde olation Tests are NOT required DESIGN If any portion of the tested area is in the A/ - .H63.09 15)Ibl, indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH i NUMBER DEPTH IN, ELEVATION OBSERVED ST. GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) /V$ e— � t B- a A lt < 1 o -i '- r ,,�,• /S is - a S f3� � � �.s $5�%K.�' B- 3 e- b r .p !ice 45 B- 4 7y B- PERCOLATION TESTS DROP IN WATER LEVEL - INCHES RA P (INCH ES TEST DEPTy WATER IN HOLE TEST TIME ER NUMBER AFTER WELLING INTERVAL -MIN. P R D 1 P I " e G P- G G L P _ '!t i P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION �--- -- f i t } _ r� 1 a V F. I j _m 4 t TH T , ' -I T _ I t s F 4 R d � 1 _ - } �z � . 1v ' . I � I, the undersigned, hereby soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. TESTS W ERE COMPLETED ON: FADDPESS print : r 1 r D 'Pill : _ CE RTIFICA ION NUMBER: PHONE NUMBER (option all: CST SI NATU E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — PLOT PLAN O�ECT 4a1 U AeJ ADDRESS�-Z 1� �"�lia� �/ s /4 �: 1/4/SAj /T 1 N /R/ W TOWN t; C UNTY _ r-- MPRS Byron Bird Jr. 3318 DATE / — BEDROOM3 CLASS PERC CONVENTIONALj<IN- PRESSURE CONVENTIONAL LIFT MOUND_ HOLgANG TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE 40 HOLDING TANK SIZE ABSORPTION AREA 6 PERC RATE A BED SIZE 1L Benchmark V.R.P. Assume Ele ation 100' Location of Benchmark X / -0 la r S -� �G O� '14e/ ° * H.R.P. / c 0 Borehole Well Scale Feet i O Perc Hole System Elevation TYPAR COVERING 2" 12 3- 0 6' 0 3' Sewer Rock , 6 12' P 4� v a� ®12 I n h -e s t- r v K J d ,Aw a o l ��° ,� ,. d 'e 'e. �� ,�s ��r� ..,.,. �.. ..._.,,�......:F..�.....::,....